Method of detecting surrogate markers in a serum sample

ABSTRACT

The invention provides a method of detecting surrogate markers for active tuberculosis in a serum sample. The surrogate markers are selected from serum mycolic acid antigen, serum anti-mycolic acid antibodies or both. The method includes the steps of combining the serum sample with a labelled monoclonal immunoglobulin antibody or fragment thereof to mycolic acids to produce a combined serum sample, the antibody or fragment thereof not substantially cross-reacting with cholesterol and the label being selected so that binding of the labelled antibody to immobilized mycolic acid antigen of mycobacterial origin produces a detectable signal and combining a blank sample with the labelled monoclonal immunoglobulin antibody or fragment thereof to mycolic acid to produce a combined blank sample. The method includes exposing both samples to immobilised mycolic acid antigen of mycobacterial origin or a synthetic analogue or analogues thereof so that the labelled immunoglobulin antibodies or fragments thereof in each sample bind to the immobilised antigen to produce detectable signals. If the surrogate markers are present, the signal produced by the blank sample will be stronger than that produced by the serum sample because of inhibition of binding of the labelled antibody in the serum sample arising from prior binding of the labelled antibody with the mycolic acid antigen in the serum sample or by competitive binding of serum anti-mycolic acid antibodies in the serum sample to the immobilised mycolic acid antigen or both.

THIS INVENTION relates to a method for detecting active tuberculosis. Itrelates, in particular, but not exclusively to a method which can beused at point of care clinics.

More specifically, the invention relates to a serodiagnostic method fortuberculosis or TB based on the prevalence in mammalian subjects ofeither antibodies to lipid antigens, or lipid antigens derived fromMycobacterium tuberculosis. For a disease such as tuberculosis, therehas to date been no acceptable serodiagnostic assay, despite the factthat much progress has been reported in studies of antibodies to variousantigens of M. tuberculosis in the serum of patients with TB (Pan etal., 1999; Julian et al., 2002; Schleicher et al., 2002; Lopez-Marin etal., 2003; Pottunarthy et al., 2000, Steingart et al., 2007).

South Africa currently has the highest incidence of TB per 100 000people in the world. In 2007 alone 112 000 people died of TB in SouthAfrica, of which 94 000 were co-infected with HIV (WHO, 2009). Twothirds of these deaths could be prevented if they were diagnosed intime. One of the biggest challenges facing clinicians is the time ittakes to accurately diagnose TB. Currently, using the conventionalmethods, it takes on average 4 weeks to diagnose TB which leads to adelay in treatment of the disease. If a fast diagnosis is availablepatients would receive anti-TB therapy immediately and becomenon-infective within a few days. With the current methods of diagnosis,patients with persistent symptoms have to remain in quarantine forseveral weeks while awaiting the results. During this time, they caninfect the medical staff, their next of kin or anyone with whom theyshare a closed area, such as in public transport. The rise of MDRand XDRTB poses a threat of spreading among hospital staff and the communitiesan almost incurable disease that can be fatal within two months. Theneed for a fast, reliable diagnostic tool for TB is therefore high,especially in high HIV incidence populations (Wood et al., 2007).

Immunodiagnostic assays detecting pathogen related antibodies in patientsera with active TB disease is an attractive alternative for rapiddiagnosis. An array of mycobacterial cell wall components have beenconsidered as antigens for surrogate marker antibodies for TB in thepast (Fujiwara et al., 1999; Lyashcenko et al., 1998, Nabeshima et al.,2005). Antigenic activity of mycolic acids and the glycolipidderivatives such as the lipid extractable trehalose mono- ordimycolates, TMM or TDM respectively (cord factors) have been reviewedrecently (Sekanka et al., 2007). Of all the antigens prevalent in thecell wall of the mycobacteria that may be considered for use in TBserodiagnosis, mycolic acids provide a special opportunity due to theirabundance, variability among different species of Mycobacterium and theunique way that they communicate their presence to the immune responseof the host (Sekanka et al., 2007; Shui et al., 2007; Yuan et al.,1997). The ability of mycolic acids to elicit CD4-, CD8-double negativeT cells by means of their presentation on CD1b proteins of dendriticcells (Beckman et al., 1994) may well be the reason that the antibodytiters to mycolic acids in AIDS patients with even very low CD4 T cellcounts are maintained, relative to other patients that are not infectedwith HIV, or have normal CD4 T cell counts (Schleicher et al., 2002).Pan et al. have shown that the most antigenic part of the cord factorantigen was the mycolic acid (Pan et al., 1999).

The use of mycolic acid antigens to detect antibodies as surrogatemarkers for TB diagnosis was shown to be feasible in an ELISA assay (Panet al., 1999; Schleicher et al., 2002), albeit of limited accuracy. Onecomplication was the cross-reactivity of human serum antibodies betweenmycolic acids and cholesterol that gave rise to a high antibody bindingsignal with human TB negative sera against mycolic acid. This was mostlikely due to a shared structural feature between cholesterol and afolded form of mycolic acid, as both cholesterol and mycolic acids couldbe liganded by Amphotericin B, a cholesterol binding drug (Benadie etal., 2008). The cross-reactivity could be due to a mixture ofmonospecific anti-cholesterol and anti-MA antibodies in the sera, or dueto a true cross-reactivity where a particular antibody specificity couldrecognize both mycolic acid and cholesterol. It is known that all humanshave anti-cholesterol antibodies in their blood circulation (Swartz etal., 1988), which may explain the high antibody activity to mycolicacids in TB negative patients. A biosensor approach showed improvedaccuracy to a level that may warrant consideration forcommercialization, when using free mycolic acids in liposomes asantigens in a competitive binding assay (Lemmer et al., 2009; Thanyaniet al., 2008). This test, subsequently dubbed the MARTI-test (forMycolic acids Antibody Real-Time Inhibition), can diagnose TB withinfour hours of sampling by analyzing the serum sample for the presence ofanti-mycolic acid antibodies as immune surrogate markers for active TBthat is accurate even in HIV infected patients. The use of theinhibition of binding of antibodies in a real-time immunoassay seemed tolargely solve the problem of cross-reactivity between mycolic acids andcholesterol.

Mycolic acids (MA) are high molecular weight, α-alkyl, β-hydroxyl fattyacids and are characteristic components of the cell envelope ofmycobacteria and some other bacterial genera. In the mycobacterial cellenvelope, MA are present as free lipid esters, such as trehalosedimycolate (TDM) or cord factor and trehalose monomycolate (TMM), butfor the most part, they are esterified to the terminalpenta-arabinofuranosyl units of arabinogalactan, a peptidoglycan-linkedpolysaccharide (Brennan and Nikaido, 1995). The presence of suchlong-chain fatty acids is largely responsible for the highhydrophobicity and very low permeability of the mycobacterial cellenvelope (Lee et al., 1996). The number of carbon atoms that make up theMA varies from C₂₀ to C₃₆ in the genus Corynebacterium to C₆₀ to C₉₀ inthe genus Mycobacterium. MA of the Nocardia and Rhodococcus species havelengths ranging from C₃₆ to C₆₆ (Butler et al., 1991). Mycobacterial MAcompose about 40-60% of the dry weight of the cell wall of the bacteria(Brennan and Nikaido, 1995; Lee et al., 1996). Because of the uniquenessof the structures of mycolic acids to the pathogenic Mycobacteriumtuberculosis, they provide ideal antigens for serodiagnosis oftuberculosis.

Mycolic acids comprise a large number of various structures within andamong Mycobacterium species and in a few other genera. In M.tuberculosis, they consist mainly of alpha-, keto- and methoxy-MAsubclasses, each of varying chain lengths and particular stereochemicalstructure around the functional groups in the main (mero-) chain (Dobsonet al. 1985). Whether all, a few, or one of these MAs are detected asantigens by TB patient antibodies is not clear at this stage and is afocus of current research. Pan et al. (1999) indicated that theoxygenated natural MAs, i.e. keto- and methoxy-MA, are more antigenicthan the non-oxygenated alpha MA, but the observations are not yetconclusive as the MAs were tested as methyl-esters, rather than as freemycolic acids. A more sensitive and specific diagnostic assay couldpossibly be developed by making use of specific synthetic stereocontrolled mycolic acid subclasses instead of using natural mixtures ofMA that could differ between batches. Because different MA subclassesdominate in certain stages of the growth of mycobacteria or stage ofdisease, it could also be that a specific synthetic MA antigen couldprovide more reliable data, reveal information on the stage of thedisease and be better able to distinguish between TB positive and TBnegative patient sera. Achievement of the stereocontrolled chemicalsynthesis of various subclasses of mycolic acids representative of thosethat appear in the cell wall of M. tb was reported since 2005 (AlDulayymi 2005, 2006 and 2007, Toschi 2006, Koza 2007).

DESCRIPTION OF THE STATE OF THE ART

Patent Application No. PCT/GB95/00856 (Verschoor and Bye, 1995)describes the incorporation of mycolic acid in an immunogenic conjugatewhich elicited specific antibody production in mice. Optimization of aprocedure for extraction and purification of mycolic acids ofmycobacteria was disclosed in Patent Application No. PCT/GB96/00416(Verschoor, 1996 and Goodrum et al., 2001). The immunological propertiesof the mycolic acids were tested in TB infected animals and in vitrocultures of human cells to explore the potential for broader applicationof the patented principles and products of tuberculosis. This work hasbeen compiled in subsequent Patent Application No. PCT/GB98/00681(Verschoor et al., 1998) and published (Korf et al., 2005). In the USA,four divisional patent applications based on this patent applicationwere filed of which divisional application PAl29709/US relating to theuse of anti-mycolic acid antibodies in human subjects as surrogatemarkers for TB infection was conditionally allowed in the USA in 2002.The claims were substantiated by the presentation of experimental datain 2005, when the prevalence of anti-mycolic acid antibodies in serumsamples of human TB patients could be demonstrated with adequateaccuracy using wave-guide biosensor technology (Verschoor et al. 2005,Thanyani et al. 2008). The test was subsquently named the MARTI test forTB serodiagnosis (Lemmer et al. 2009) and shown to work in a surfaceplasmon resonance biosensor as well. It was also shown to work by meansof electro-impedance spectroscopy (Mathebula et al. 2009, Ozoemena etal. 2010).

In its configuration as an evanescent field or electro-impedancebiosensor, the MARTI-test remains laboratory bound, i.e. suitable onlyfor use in a TB reference laboratory. This is due to the requirement ofhighly skilled laboratory staff, sophisticated equipment and anair-conditioned, dust free environment. In order for the process to workin the field, i.e. at the point of care clinics, it would be desirableif the principles of the MARTI-test could be reconfigured in a simpledip-stick format as a lateral flow immunoassay.

Lateral flow immunoassays were first described in the 1960s and havesince become popularly known as ‘dip-stick tests’. The first commercialapplication was a home pregnancy test launched in 1988. Since then, thetechnology has been applied in a range of tests for clinical,veterinary, agricultural, food industry and environmental applications.Dip-stick strip tests are versatile and are available for a range ofanalytes from low molecular weight molecules and proteins to wholeviruses and bacteria. Variations of the technology have been developedinto a number of commercial products, but they all operate according tothe same basic principle (adapted from Food Safety Info,www.foodsafetywatch.com, viewed in March 2010).

In a dip-stick immunoassay, lateral flow of sample and reagents occuralong a single axis on a test strip format, starting from a sampledeposition pad, followed by a conjugate pad and proceeding over areaction membrane towards a wick that serves as a waste reservoir (asshown in FIG. 1). The sample pad is an absorbent pad onto which the testsample is applied. Antibodies or antigen binding fragments of antibodiesdirected to the target analytes are put in the conjugate or reagent pad.They are conjugated to reporter molecules such as colloidal gold orfluorophores. The reaction membrane is typically composed of ahydrophobic nitrocellulose or cellulose acetate membrane onto whichanti-target analyte antibodies are immobilised in a line across themembrane as a capture zone or test line. A control zone may also bepresent that contains antibodies specific for the conjugate antibodies.In competitive immunoassay dip-sticks, the capture zone on the membranemay contain immobilised antigens. The wick or waste reservoir is afurther absorbent pad designed to draw the sample across the reactionmembrane by capillary action and collect it. The components of the stripare usually fixed to an inert backing material and may be presented in asimple dipstick format or within a plastic casing with a sample port andreaction window showing the capture and control zones.

There are two main types of lateral flow immunoassay, namely doubleantibody sandwich and competitive assays. In double antibody sandwichassay the sample migrates from the sample pad through the conjugate padwhere any target analyte present will bind to the conjugate. The samplethen continues to migrate across the membrane until it reaches thecapture zone where the target/conjugate complex binds to the immobilisedantibodies producing a visible line on the membrane. The sample thenmigrates further along the strip until it reaches the control zone,where excess conjugate binds to produce a second visible line on themembrane. This control line indicates that the sample has migratedacross the membrane as intended. Two clear lines on the membrane is apositive result. A single line in the control zone is a negative result.Double antibody sandwich assays are most suitable for larger analytes,such as bacterial pathogens and viruses, with multiple antigenic sites.Competitive assays are primarily used for testing small molecules anddiffer from the double antibody sandwich format in that the conjugatepad contains labelled antibodies that are already bound to a targetanalyte, or to an analogue of it. If the target analyte is also presentin the sample it will therefore not bind with the conjugate and willremain unlabelled. As the sample migrates along the membrane and reachesthe capture zone an excess of unlabelled analyte will bind to theimmobilised antibodies and block or outcompete the capture of theconjugate, so that no visible line is produced. The unbound conjugatewill then bind to the antibodies in the control zone producing a visiblecontrol line. A single control line on the membrane is a positiveresult. Two visible lines in the capture and control zones is a negativeresult. However, if an excess of unlabelled target analyte is notpresent in the sample, a weak line may be produced in the capture zone,indicating an inconclusive result. Competitive assays are most suitablefor testing for small molecules unable to bind to more than one antibodysimultaneously. There are a number of variations on lateral flowtechnology. The capture zone on the membrane may contain immobilisedantigens rather than antibodies. It is also possible to apply multiplecapture zones to create a multiplex test.

Lateral flow immunoassays are simple to use by untrained operators andgenerally produce a result within 15 minutes. They are very stable androbust, have a long shelf life and do not usually require refrigeration.They are also relatively inexpensive to produce. These features makethem ideal for use at the point-of-care and for testing samples in thefield, as well as in the laboratory. However, their sensitivity islimited without additional concentration or culture procedures.

While most lateral flow immunoassays are only capable of providing aqualitative result, it is possible to obtain some degree ofquantification by measuring the amount of conjugate bound to the capturezone. This can be done using a dedicated reader to measure the intensityof the coloured test line. More sophisticated techniques, such asfluorescent dye labelled conjugates, have also been developed to improvethe quantitative potential of lateral flow assays.

The present invention provides a lateral flow immunoassay specificallyfor diagnosis of tuberculosis from a few drops of blood from thepatient. The test is specifically aimed to give a first indication of TBat a point of care setting such as a rural clinic. It will be ofparticular benefit to communities where HIV abounds, as the test shouldnot be affected by co-infection of the patient with HIV. At thecompletion of the test, the user may read the test results by eye, orhave it measured in a specifically designed scanner that gives aquantitative readout. If both the test and control lines are coloured,the test is negative for TB. If only the control line is coloured, thetest is positive for active TB. The test is referred to as MALIA(Mycolic acids Antibodies Lateral flow Immuno Assay).

SUMMARY OF THE INVENTION

The invention provides a method of detecting surrogate markers foractive tuberculosis in a serum sample, the surrogate markers beingselected from serum mycolic acid antigen arising from tuberculousmycobacterial infection, serum anti-mycolic acid antibodies arising fromtuberculous mycobacterial infection or both, the method including thesteps of

combining the serum sample with a labelled monoclonal immunoglobulinantibody or fragment thereof to mycolic acids to produce a combinedserum sample, the antibody or fragment thereof not substantiallycross-reacting with cholesterol and the label being selected so thatbinding of the labelled antibody to immobilized mycolic acid antigen ofmycobacterial origin produces a detectable signal;

combining a blank sample with the labelled monoclonal immunoglobulinantibody or fragment thereof to mycolic acid to produce a combined blanksample; and then

exposing both the combined serum sample and the combined blank sample toimmobilised mycolic acid antigen of mycobacterial origin or a syntheticanalogue or analogues thereof so that the labelled immunoglobulinantibodies or fragments thereof in each sample bind to the immobilisedantigen to produce detectable signals, the signal produced by thecombined blank sample being stronger than that produced by the combinedserum sample because of inhibition of binding of the labelled antibodyin the exposed serum sample arising from prior binding of the labelledmonoclonal antibody with the mycolic acid antigen in the serum sample orby competitive binding of serum anti-mycolic acid antibodies in theserum sample to the immobilised mycolic acid antigen or both.

The method may include combining the serum sample and the blank samplein a conjugate pad of a lateral flow immunoassay device and exposing thecombined serum sample and the combined blank sample to immobilizedmycolic acids in a capture zone of the lateral flow immunoassay device.The sample may be of human or animal origin.

The method may then include exposing the remainders of the combinedserum sample and the combined blank sample to immobilizedanti-immunoglobulin antibodies in a control zone of the lateral flowimmunoassay device.

The analyte serum antibodies may thus be antibodies againstMycobacterium tuberculosis, or antibodies against part thereof. Theantibodies may be of the types that demonstrate cross-reactivity towardssterols such as cholesterol. The antibodies may be low affinityantibodies

The serum sample and the blank sample may thus be exposed to thelabelled antibody or fragment thereof in a conjugate pad, after whichthey migrate to a capture zone where the exposed serum sample and theexposed blank sample are exposed to the immobilised antigen. From there,the remainders of the serum sample and the blank sample migrate to acontrol zone where they are exposed to the immobilizedanti-immunoglobulin antibodies that can bind unbound labelled antibodyor fragment thereof onto the control zone. The capture and control zonesthus make up two zones of the lateral flow immunoassay device.

The labelled monoclonal immunoglobulin antibody or fragment thereof maybe labelled with colloidal gold or with a suitable fluorophore orchromophore such as latex or fluorescent beads so that the signal is acolour signal. For example a significantly faded colour in the capturezone for the serum sample in comparison to that of the blank sample willthus indicate a positive result, under the condition that the controlzone exposed to either serum sample or blank sample both become equallycoloured. When gold coated colloidal particles mix, they produce colourof low-density, due to natural repellent forces that keep them at adistance from one another. When gold-labelled antibody binds toimmobilised antigen, the repellent forces between the gold particles areovercome. The gold particles then merge their magnetic fields with oneanother and produce an intense colour in the visible spectrum.

According to a second aspect the invention provides a method ofdetecting surrogate markers for active tuberculosis in a serum sample bylateral flow immunoassay using a lateral flow assay device, the deviceincluding a sample pad, a conjugate pad, a capture zone, at least twolanes and optionally a control zone, the surrogate markers beingselected from serum mycolic acid antigen arising from tuberculousmycobacterial infection, serum anti-mycolic acid antibodies arising fromtuberculous mycobacterial infection or both, the method including thesteps of

immobilizing isolated mycolic acid antigen of mycobacterial origin or asynthetic analogue or analogues thereof in the capture zone,

optionally immobilizing anti-immunoglobulin antibodies that recognizethe monoclonal antibody or fragment thereof in the control zone,

providing a labeled monoclonal immunoglobulin antibody or fragmentthereof to mycolic acids in the conjugate pad, the antibody notsubstantially cross-reacting with cholesterol and the label beingselected so that binding of the labelled antibody or fragment thereof tothe mycolic acid antigen of mycobacterial origin produces a detectablesignal,

applying the serum sample from a person or animal suspected of havingtuberculosis to the sample pad of a first lane of the lateral flowdevice;

applying a blank sample comprising a buffer solution to the sample padof a second lane of the lateral flow device;

allowing the serum sample and the blank sample to be transferred to theconjugate pad so that the serum mycolic acid antigen, the serumanti-mycolic acid antibodies or both in the serum sample and the buffersolution in the blank sample mix in the conjugate pad with the labelledmonoclonal immunoglobulin antibody;

allowing the serum sample with the labelled monoclonal immunoglobulinantibody in the first lane and the blank sample with the labelledmonoclonal antibody in the second lane to be transferred to the capturezone to allow binding of the labelled monoclonal antibody and the serumanti-mycolic acid antibody in the first lane and the labelled monoclonalantibody in the second lane to the immobilised mycolic acid in thecapture zone and detecting inhibition of binding of the labelledantibody to the mycolic acid antigen in the capture zone by a reductionin the strength of the signal produced by the serum sample, compared tothat produced by the blank sample because of inhibition of binding ofthe labelled monoclonal antibody arising from prior binding with theserum mycolic acid antigen in the serum or by competitive binding ofserum anti-mycolic acid antibodies in the serum sample to theimmobilised mycolic acid antigen, or both; and

optionally allowing remainders of the combined serum sample and thecombined blank sample to be transferred to the control zone to allowbinding of the remaining labelled monoclonal antibody to the immobilisedanti-immunoglobulin antibodies in the control zone in order to confirmthat the flow of serum sample and blank sample to the absorbent padhappened in both lanes by the appearance of binding signals on thecontrol zones in both lanes

According to a third aspect, the invention provides a lateral flowimmunoassay device for detecting surrogate markers for activetuberculosis in a serum sample, the surrogate markers being selectedfrom serum anti-mycolic acid antigen arising from tuberculousmycobacterial infection, serum mycolic acid antibodies arising fromtuberculous mycobacterial infection or both, the device including asample pad, a conjugate pad, a capture zone and, optionally, a controlzone, the conjugate pad containing a labelled monoclonal immunoglobulinantibody to mycolic acids which is not substantially cross-reactive withcholesterol, the label being selected so that binding of the labelledantibody to mycolic acid antigen of mycobacterial origin produces adetectable signal, the capture zone comprising immobilised isolatedmycolic acid antigen of mycobacterial origin or a synthetic analogue oranalogue thereof and the optional control zone comprising immobilisedanti-immunoglobulin antibodies that can bind to the labelled monoclonalantibodies.

The labelled monoclonal immunoglobulin antibody or fragment thereof tomycolic acids may be a colloidal gold labelled monoclonal immunoglobulinantibody or fragment thereof to mycolic acids. The mycobacterialinfection may be of the type which causes diseases selected frompulmonary tuberculosis and other forms of tuberculosis. The serummycolic acid antigen may be a from mycobacteria selected from virulentand pathogenic tuberculous mycobacteria. In particular, the mycolic acidantigen may be derived from Mycobacterium tuberculosis.

The monoclonal immunoglobulin antibody may be a recombinant singlechain, variable fragment of monoclonal immunoglobulin (scFv) directed tomycolic acid. The scFv antibody fragment may be selected from avertebrate immunoglobulin gene library. In particular, the scFv antibodyfragment may be selected from a chicken immunoglobulin gene library.

The scFv antibody fragment may be substituted by a larger fragment ofthe immunoglobulin or the full monoclonal immunoglobulin or by a numberof fragments linked to a carrier protein. The serum mycolic acidantibodies may include types that demonstrate cross-reactivity towardssterols. The scFv antibody fragment may have the amino acid sequence ofSeq ID No 1 and/or be encoded by the nucleotide sequence of Seq ID No 2or a fragment thereof.

The labelled antibody may thus be a labelled, recombinant, single chain,variable fragment of monoclonal immunoglobulin (scFv) directed tomycolic acids. The blank sample may be phosphate buffered saline. Thelabelled antibody is accordingly specific for antigens arising frommycobacterial infection.

The method of the invention can be used in all humoral fluidtuberculosis diagnostics, such as those using serum, plasma, pleuralfluid, peritoneal exudate fluid and cerebrospinal fluid. The method ofthe invention will preferably be carried out using a lateral flowimmunoassay device. The analyte may thus be the human serum antibody tothe mycolic acid antigen, and/or the mycolic acid antigen itself and thesample of human or animal origin may thus be selected from bloodsamples, spinal fluid samples and samples that naturally containantibodies and, if the human or animal has active mycobacterial disease,the sample will contain antibodies to the mycobacterial pathogen.

The method may include allowing the exposed samples to be transferred tothe control zone, after interaction with the capture zone so thatremaining labelled monoclonal immunoglobulin or fragments thereof canbind to anti-immunoglobulin antibodies immobilized in the control zoneto produce a coloured signal indicating that the lateral flow ofreagents occurred and that the reagents are active.

The labelled monoclonal immunoglobulin antibody or a fragment thereofmay be as hereinbefore described.

The antigen may be immobilised using the process described in Benadie etal., 2008. The presence of either mycolic acids from tuberculousmycobacteria, or antibodies directed to them in the sample serum areindicators of active tuberculosis in the human or animal from which thesample originated.

The mycolic acid antigen used for immobilization in the capture zone maybe in a form selected from homogenous and heterogenous compoundmixtures. The mycolic acid antigen used for immobilization in thecapture zone may be immobilized on microparticles. Such methods areknown to those skilled in the art. The immobilisation may be carried outaccording to the process of Benadie et al., 2008. The antibody componentof the conjugate will preferably be directed to mycolic acid fromtuberculous mycobacteria, but that does not cross-react withcholesterol. The sample may be from an HIV positive human. It may befrom a child.

The invention thus provides a monoclonal antibody or fragment thereoffor use in diagnosis of active tuberculosis from humoral fluid samples.The monoclonal antibody or fragment will be used, in particular, inpoint of care diagnostics of patient humoral fluid samples for activetuberculosis. The monoclonal antibody of the invention preferablydetects mycolic acids from tubercular mycobacterial origin but does notcross-react with cholesterol. The monoclonal antibody may be arecombinant monoclonal antibody or fragment thereof and may be derivedfrom an antibody gene library. The antibody gene library may be a germline gene library and may be from chicken origin.

The invention further provides a method of detecting surrogate markersfor active tuberculosis in a serum sample, the surrogate markers beingselected from serum mycolic acid antigen arising from tuberculousmycobacterial infection, serum anti-mycolic acid antibodies arising fromtuberculous mycobacterial infection or both, the method including thestep of exposing a labelled monoclonal antibody having the amino acidsequence of Seq ID No 1 and/or which is encoded by the nucleotidesequence of Seq ID No 2 or a fragment thereof to the serum sample.

The invention further provides the use of a monoclonal antibody havingthe amino acid sequence of Seq ID No 1 and/or which is encoded by thenucleotide sequence of Seq ID No 2 or a fragment thereof in themanufacture of a device for use in a method of detecting surrogatemarkers for active tuberculosis in a serum sample, the surrogate markersbeing selected from serum mycolic acid antigen arising from tuberculousmycobacterial infection, serum anti-mycolic acid antibodies arising fromtuberculous mycobacterial infection or both.

The invention further provides a monoclonal antibody having the aminoacid sequence of Seq ID No 1 and/or which is encoded by the nucleotidesequence of Seq ID No 2 or a fragment thereof.

The invention further provides a method of detecting surrogate markersfor active tuberculosis in a serum sample, the surrogate markers beingselected from serum mycolic acid antigen arising from tuberculousmycobacterial infection, serum anti-mycolic acid antibodies arising fromtuberculous mycobacterial infection or both, the method including thestep of applying the serum sample and a blank sample to a lateral flowimmunoassay device as claimed in any one of claims 5 to 14 inclusive.

The protein (amino acid) sequence shown in Scheme 1 (see SEQ ID No 1 andencoded by the nucleotide sequence of SEQ ID No 2) was derived from thechicken genome, except for the residues shown in bold, which wererecombinantly introduced to effect expression and purification as afunctional single chain variable antibody fragment (scFv)

Scheme 1 MKYLLPTAAAGLLLLAAQPAMAARWTSPGAASRRPEEGSASSARPPGXPAVTAWVGCDRRLAKGWNGSLVLMMMVVSHTTGRRRAVPPSRGTTGRAQGCSTTSGLRTPAPTLAPKIIILYDYRRMGPGTEVIVSSGGGGSGGGGSGGGGSALTQPSSVSANPGEIVEITCSGSDSSNNYGWYQQKAPGSAPVTVIYDNTNRPSNIPSRFSGSTSGSTATLTITGVQAEDEAAYFCPSTDSIFGAGTTLTVLGQPNAAAEQKLISEEDLNPeIB vector sequence: MKYLLPTAAAGLLLLAAQPAMAc-Myc purification sequence: EQKLISEEDLNLinker stabilisation sequence: GGGGSGGGGSGGGGS

The monoclonal scFv antibody fragment may be selected from anyvertebrate immunoglobulin gene library. It may, for example, be selectedfrom a chicken immunoglobulin gene library. Preferably, it will beselected for a particular affinity and specificity of binding to mycolicacids from experimentally mutated immunoglobulin genes or immunoglobulingene libraries. In the method of the invention, the scFv antibodyfragment can be substituted by a larger fragment of the immunoglobulinor by the full monoclonal immunoglobulin, or by a number of thefragments linked to a carrier protein.

The analyte antibodies in the sample may be of the types thatdemonstrate cross-reactivity towards sterols.

Further features of the invention will now become apparent in thefollowing description with reference to the Figures, the followingnon-limiting examples and the sequence listings, in which

FIG. 1 shows a typical lateral flow composition (Indicia Biotechnology),and

FIG. 2 shows Chicken scFv antibody fragment recognition of mycolic acid(4=ma mix) and cholesterol (3=ch) with ELISA. Three scFv specificitieswere identified, which were denoted Anti-MA (grey bars), Anti-CH (blackbars) and Cross rxtive (blank bars). Mycolic acid and cholesterolantigens were coated from hexane, while results on hexane only(1=Hexane) and PBS only (2=PBS) sham coated wells are indicated as well.The error bars indicate the standard deviation of four repeats.

EXAMPLE 1 Generation and Characterization of Recombinant Monoclonal scFvAntibody Fragments to Mycolic Acids and Cholesterol 1 Materials andMethods 1.1 Generation of Recombinant Monoclonal scFv 1.1.1 PhageDisplay Antibody Library

A naive semi-synthetic chicken phage display library was used (VanWyngaardt et al., 2004). The library contains recombinant filamentousbacteriophages displaying scFv antibody fragments. These fragments werederived from combinatorial pairings of chicken V_(H) and V_(L)immunoglobulin domains. V_(H) and V_(L) domains are linked by aninterpeptide segment consisting of the sequence (GGGGS)₃, enabling afold typical of single variable fragments.

1.1.2 Phage Display Antibody Selection

A selection of the phages displaying mycolic acid reactive scFv's wasconducted by several panning rounds. Maxisorp immunotubes (Nunc-ImmunoTubes, Nunc, Denmark) were coated with 100 μg/ml mycolic acid (SigmaAldrich) dissolved in distilled hexane, after which the hexane wasallowed to evaporate at room temperature. Coated immunotubes werebriefly washed with phosphate buffered saline (PBS, pH 7.4), thenblocked with 2% skimmed milk in phosphate buffered saline (2% MPBS) for60 min. Tubes were then exposed to 10¹² transforming units of the phagelibrary in 2% MPBS, 0.1% Tween-20 buffer for 2 hrs. Unbound phage wereremoved by 10× washing with PBS containing 0.1% Tween-20 followed by afurther 10× wash with PBS to remove the Tween-20. Bound phage was elutedwith 100 mM triethylamine and neutralized with 1M Tris, pH 7.4. Forenrichment Escherichia coli TG1 was infected with eluted phages, grownat 30° C. in 2×TYG broth (TY broth supplemented with 2% glucose)containing 100 μg/ml ampicillin, and rescued with M13-K07 helper phage(Invitrogen). Panning was repeated four times.

1.1.3 Screening of Mycolic Acid Specific Phage Clones

Following the final panning, individual ampicillin resistant E. coli TG1colonies were selected for further characterization. Colonies were grownin 2×TYG broth supplemented with 100 μg/ml ampicillin in 96-wellMicrotitre plates at 30° C. Phages were rescued as described previously(Van Wyngaardt et al., 2004). Phage clones were screened byenzyme-linked immunosorbent assay (ELISA) carried out with mycolic acidcoated microtitre plates (Maxisorp, Nunc, Denmark). Coating was done byadding 50 μl of 100 μg/ml mycolic acid in hexane in each well and dryingit overnight at room temperature. Wells were briefly washed with PBS,and blocked with 300 μl of 2% MPBS for 60 min. Phage containingsupernatants (25 μl) were mixed with blocking solution (25 μl), added toeach well, and incubated for 60 min at 30° C. Wells were washed threetimes with PBS-0.1°)/0 Tween-20. Mouse monoclonal antibody B62-FE2,specific for M13 filamentous phage, in 2% MPBS-0.1% Tween-20 (50 μl) wasadded to each well and further incubated for 60 min at 30° C. Boundphages were detected using rabbit anti-mouse IgG antibody conjugatedwith horseradish peroxidase (HRP). Signals were developed with3,3′,5,5′-tetramethylbenzidine (Pierce, USA) using the 1-stepUltra TMBELISA substrate solution according to manufacturer's instructions.Plates were read using a Multiskan Ascent (Thermo Labsystems) platereader at a wavelength of 450 nm.

1.1.4 DNA Sequence Determination and Analysis

Phage DNA was isolated using a NucleoSpin Plasmid kit (Macherey-Nagel,GmbH). Each scFv construct was sequenced using sequencing primers, M13reverse and 5′-CCCTCATAGTTAGCGTAACG-3′. The sequences were determinedusing the Big Dye 3.1 terminator chemistry (Applied Biosystems, U.S.A)and analysed with BioEdit version 3.1.

1.1.5 Production and Purification of Mycolic Acid Reactive scFv

Selected anti-mycolic acid phage obtained from E. coli TG1 clones wasused to infect E. coli HB2151 to obtain soluble scFv. Single colonieswere grown to an OD₆₀₀ of 0.9 in 2× TYG broth supplemented with 100μg/ml ampicillin at 37° C. ScFv expression was induced with isopropylβ-D-thiogalactosidase (IPTG; 1 mM) and the culture further incubated at30° C. overnight, in glucose free media. Soluble scFv was extracted,with 1× TES buffer, from the periplasm as previously described (Hugo etal., 2002). ScFv was further affinity purified using an anti c-myc tagmAb. The column was prepared by immobilising 9E10 IgG onto aminoLinkPlus gel (Pierce) according to manufacturer's instructions. Periplasmicextracts were applied and after washing with PBS, bound scFv was elutedwith 100 mM triethylamine and neutralised with 1 M Tris, pH 7.4. ElutedscFv was dialyzed against 1×PBS, pH 7.4 at a MW cut-off of 10 KDa.Samples were concentrated using a Macrosep® ultrafiltration device (Palllife sciences, USA) and protein concentrations determined with a BCAprotein detection kit (Pierce, USA), according to the manufacturer'sinstructions. Purified scFv was stored at −20° C. until further use.

1.1.6 Characterization of scFv's Binding Specificity of Mycolic Acids bySandwich ELISA

Purified scFv's were tested for their binding activity using a sandwichELISA. Maxisorp immunoplates were coated with mycolic acid as follows:The lipid samples (250 μg) were dissolved in hexane (4 ml, distilled)and vortexed for 30 s. One vial of hexane (4 ml) served as control.Solutions were coated using a Hamilton syringe (50 μl/well) and theliquid was loaded in the centre of the wells. Lipid was visible as acircular waxy layer after 2 hours of evaporation of the hexane at roomtemperature. The plates were then stored in plastic bags at 4° C.overnight. Plates were blocked with 2% MPBS for 60 min at 30° C.followed by a brief washing step with PBS. ScFv samples (25 μl) weremixed with 2% MPBS (25 μl), added to the wells and incubated for 60 min.Unbound scFv was removed by 3× washing with PBS-0.1% Tween-20. Antic-myc monoclonal antibody (AbD serotec, UK) conjugated with HPR was usedto detect bound scFv fragments. Signals were developed with3,3′,5,5′-tetramethylbenzidine using the 1-stepUltra TMB ELISA substratesolution according to manufacturer's instructions. Plates were readusing a Multiskan Ascent (Thermo Labsystems) plate reader at awavelength of 450 nm.

1.2 Results and Discussion

Monoclonal scFv Antibody Fragments to Mycolic Acid and Cholesterol

Previously, high antibody binding signal with human TB negative seraagainst mycolic acid were observed in ELISA (Schleicher et al., 2002).It was to be due to cross-reactivity of the antibodies with cholesterol,an idea that was later confirmed (Benadie et al., 2008). Thecross-reactivity could be due to a mixture of monospecificanti-cholesterol and anti-MA antibodies in the sera, or due to a truecross-reactivity where a particular antibody specificity could recognizeboth mycolic acid and cholesterol. It is known that all humans haveanti-cholesterol antibodies in their blood circulation (Swartz et al.,1988), which may explain the high antibody activity to mycolic acids inTB negative patients. To test what mechanisms are possible for thecross-reactivity, scFv fragments expressed from a chicken antibody genelibrary were screened for specific binders to cholesterol and mycolicacid. Three different specificities were detected and worked up from thephage display system into monovalent, monoclonal scFv fragments. Themono-specific anti-cholesterol scFv was dubbed anti-CH, while two scFvspecificities were generated against mycolic acids: one monospecific(Anti-MA) and one cross-reactive with cholesterol (Cross rxtive). FIG. 2shows the characterization of these three scFv's with ELISA. The factthat a monoclonal and monovalent cross-reactive scFv could be foundagainst either cholesterol or MA corroborates the conclusion reported byBenadie et al. (2008) that cholesterol and MA share antigenic structuralproperties. On the other hand, the finding that an scFv against mycolicacids could be found that does not cross-react with cholesterol(Anti-MA) and vice versa (Anti-CH), means that the possibility remainsthat anti-mycolic acid antibodies may be induced during tuberculosisthat do not necessarily increase the binding activity ofanti-cholesterol antibodies. This may explain why higher antibodybinding activity with TB pos patient sera was found than with TB negpatient sera in two previous reports (Schleicher et al., 2002, Thanyaniet al., 2008).

1.3 Conclusion

Two different scFv monoclonal antibody fragments generated from achicken antibody gene library that recognized mycolic acids, of whichone cross-reacted with cholesterol and the other not, indicated that thecross-reactivity of human patient serum between mycolic acids andcholesterol could either be due to a mixture of anti-cholesterol andanti-mycolic acids antibodies and/or due to a true cross-reactive singleantibody cross-reactive specificity.

The generation of an scFv antibody fragment to mycolic acids that doesnot cross-react with cholesterol opens the opportunity to develop alateral flow immunoassay for the detection of anti-mycolic acidsantibodies in human patient sera as surrogate marker for activetuberculosis. A highly specific interaction would then be expected atthe test line or capture zone, where the patient anti-mycolic acidantibodies and serum mycolic acids themselves will be able to preventthe binding of the conjugate scFv to the immobilized mycolic acid. Inthis way, a faded colour test line or capture zone will indicate thatthe patient has active tuberculosis, while full colour development willindicate that the scFv conjugate could bind unhindered, therebyindicating that neither anti-mycolic acids antibody nor mycolic acidsabound in the sample. This would be typical of a patient with no activetuberculosis.

The invention accordingly provides a scFv monoclonal antibody fragmentthat recognizes mycolic acids from tuberculous mycobacteria withoutcross-reacting with cholesterol.

Antibodies to free mycobacterial mycolic acids in the human TB patientwere not anticipated, until demonstrated for the first time in 1995(Verschoor et al 1995, PCT/GB 95/00856, Schleicher et al. 2002). Mycolicacids were presumed to occur in nature only in covalent linkage tosugars, such as the arabinogalactan cell wall glycan of mycobacteria, ortrehalose, such as in trehalose dimycolate (TDM). It was therefore notanticipated that the water insoluble mycolic acids could be secreted inan aqueous environment by mycobacteria as free fatty acid waxes, untilOhja (Ojha et al. 2008) demonstrated that free mycolic acids weresecreted by Mycobacterium tuberculosis to create a matrix for biofilmformation into which the mycobacteria embed themselves during in vitrogrowth in aqueous culture medium. That antibodies to free mycolic acidantigens could act as biomarker for active tuberculosis in human TBpatients infected with Mycobacterium tuberculosis was first shown byVerschoor (Verschoor et al, 2005) and subsequently published (Thanyaniet al. 2008).

The feasibility to detect such antibodies to diagnose TB with anaccuracy better than 80% was recognized in an international patentreview paper in 2007 (Sekanka et al. 2007). Arguing against thefeasibility of detecting antibodies to mycolic acids as biomarker foractive TB was the inventors' discovery that antibodies to mycolic acidscross-react with cholesterol (Benadie et al., 2008). It was then alreadywell-known that all humans have anti-cholesterol antibodies in theirblood, which went up in concentration when the person became subject todiseases such as AIDS that follows on infection with HIV, therebypossibly interfering with the detection of antibodies to mycolic acids(Fust et al. 2005). It appeared that if monoclonal antibodies to mycolicacids could be made that were monospecific for binding to mycolic acids,i.e. that do not cross-react with cholesterol, then such antibodiescould be uniquely applied in a lateral flow immunotest for tuberculosisdiagnosis at the point of care. A number of lateral flowimmunodiagnostic tests have been developed with monoclonal antibodiesdirected to protein antigens of Mycobacterium tuberculosis, which claimto be able to detect antibodies for the diagnosis of active TB. However,none of these has been found to meet the standards of the 1999WHO-guidelines for feasible TB diagnostic tests, despite some havingfound their way into poorly regulated diagnostic markets (Dunlap et al.2000).

The present invention is the first ever demonstration of monoclonalantibodies to mycolic acids that are not cross-reactive to cholesterol.In particular, the antibodies are clonal, recombinant antibody fragmentsfrom a synthetic chicken antibody gene library. The clonal antibodyfragments can easily be reconstructed into complete monoclonalantibodies by the skilled artist for inclusion into state of the artlateral flow immunodiagnostic devices. The application in lateral flowimmunodiagnostic devices of the non-cholesterol-cross-reactivemonoclonal antibodies to mycolic acids of the invention provides aunique opportunity for TB diagnosis at the point of care which meet theWHO standards for a valid anti-TB diagnostic test.

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1. A method for detecting surrogate markers for active tuberculosis in aserum sample, the surrogate markers being selected from serum mycolicacid antigen arising from tuberculous mycobacterial infection, serumanti-mycolic acid antibodies arising from tuberculous mycobacterialinfection or both, the method including the steps of combining the serumsample with a labelled monoclonal immunoglobulin antibody or fragmentthereof to mycolic acids to produce a combined serum sample, theantibody or fragment thereof not substantially cross-reacting withcholesterol and the label being selected so that binding of the labelledantibody to immobilized mycolic acid antigen of mycobacterial originproduces a detectable signal; combining a blank sample with the labelledmonoclonal immunoglobulin antibody or fragment thereof to mycolic acidto produce a combined blank sample; and exposing both the combined serumsample and the combined blank sample to immobilized mycolic acid antigenof mycobacterial origin or a synthetic analogue or analogues thereof sothat the labelled immunoglobulin antibodies or fragments thereof in eachsample bind to the immobilized antigen to produce detectable signals,the signal produced by the combined blank sample being stronger thanthat produced by the combined serum sample because of inhibition ofbinding of the labelled antibody in the exposed serum sample arisingfrom prior binding of the labelled monoclonal antibody with the mycolicacid antigen in the serum sample or by competitive binding of serumanti-mycolic acid antibodies in the serum sample to the immobilizedmycolic acid antigen or both.
 2. The method of claim 1, in which thestep of combining the serum sample and the blank sample is carried outin a conjugate pad of a lateral flow immunoassay device and the step ofexposing the combined serum sample and the combined blank sample toimmobilized mycolic acids is carried out in a capture zone of thelateral flow immunoassay device.
 3. The method of claim 1, whereinfollowing the step of exposing the combined serum sample and thecombined blank sample to immobilized mycolic acids, the combined serumsample and the combined blank sample are exposed to immobilizedanti-immunoglobulin antibodies.
 4. A method of detecting surrogatemarkers for active tuberculosis in a serum sample using a lateral flowimmunoassay assay device, the device including a sample pad, a conjugatepad, a capture zone, at least two lanes and optionally a control zone,the surrogate markers being selected from serum mycolic acid antigenarising from tuberculous mycobacterial infection, serum anti-mycolicacid antibodies arising from tuberculous mycobacterial infection orboth, the method including the steps of immobilizing isolated mycolicacid antigen of mycobacterial origin or a synthetic analogue oranalogues thereof in the capture zone; optionally immobilizinganti-immunoglobulin antibodies that recognize the monoclonal antibody orfragment thereof in the control zone; providing a labeled monoclonalimmunoglobulin antibody or fragment thereof to mycolic acids in theconjugate pad, the antibody not substantially cross-reacting withcholesterol and the label being selected so that binding of the labelledantibody or fragment thereof to the mycolic acid antigen ofmycobacterial origin produces a detectable signal; applying the serumsample from a person or animal suspected of having tuberculosis to thesample pad of a first lane of the lateral flow device; applying a blanksample comprising a buffer solution to the sample pad of a second laneof the lateral flow device; allowing the serum sample and the blanksample to be transferred to the conjugate pad so that the serum mycolicacid antigen, the serum anti-mycolic acid antibodies or both in theserum sample and the buffer solution in the blank sample mix in theconjugate pad with the labelled monoclonal immunoglobulin antibody;allowing the serum sample with the labelled monoclonal immunoglobulinantibody in the first lane and the blank sample with the labelledmonoclonal antibody in the second lane to be transferred to the capturezone to allow binding of the labelled monoclonal antibody and the serumanti-mycolic acid antibody in the first lane and the labelled monoclonalantibody in the second lane to the immobilized mycolic acid in thecapture zone and detecting inhibition of binding of the labelledantibody to the mycolic acid antigen in the capture zone by a reductionin the strength of the signal produced by the serum sample, compared tothat produced by the blank sample because of inhibition of binding ofthe labelled monoclonal antibody arising from prior binding with theserum mycolic acid antigen in the serum or by competitive binding ofserum anti-mycolic acid antibodies in the serum sample to theimmobilized mycolic acid antigen; and optionally, further allowing thecombined serum sample and the combined blank sample to be transferred tothe control zone to allow binding of the remaining labelled monoclonalantibody to the immobilized anti-immunoglobulin antibodies in thecontrol zone in order to confirm that the flow of serum sample and blanksample to the absorbent pad happened in both lanes by the appearance ofbinding signals on the control zones in both lanes.
 5. A lateral flowimmunoassay device for detecting surrogate markers for activetuberculosis in a serum sample, the surrogate markers being selectedfrom serum mycolic acid antigen arising from tuberculous mycobacterialinfection, serum anti-mycolic acid antibodies arising from tuberculousmycobacterial infection or both, the device including a sample pad, aconjugate pad, a capture zone and, optionally, a control zone, theconjugate pad containing a labelled monoclonal immunoglobulin antibodyto mycolic acids which is not substantially cross-reactive withcholesterol, the label being selected so that binding of the labelledantibody to mycolic acid antigen of mycobacterial origin produces adetectable signal, the capture zone comprising immobilized mycolic acidantigen of mycobacterial origin or a synthetic analogue or analoguethereof and the optional control zone comprising immobilizedanti-immunoglobulin antibodies that can bind to the labelled monoclonalantibodies.
 6. The method of claim 1, wherein the labelled monoclonalimmunoglobulin antibody or fragment thereof to mycolic acids is acolloidal gold labelled monoclonal immunoglobulin antibody or fragmentthereof to mycolic acids.
 7. The method as claimed in claim 1, whereinthe serum mycolic acid antigen is from mycobacteria selected fromvirulent and pathogenic tuberculous mycobacteria.
 8. The method of claim7, in which the serum mycolic acid antigen is derived from Mycobacteriumtuberculosis.
 9. The method of claim 1, wherein the monoclonalimmunoglobulin antibody is a recombinant single chain, variable fragmentof monoclonal immunoglobulin (scFv) directed to mycolic acid.
 10. Themethod of claim 9, in which the scFv is selected from a vertebrateimmunoglobulin gene library.
 11. The method of claim 10, in which thescFv is selected from a chicken immunoglobulin gene library.
 12. Themethod of claim 9, wherein the scFv is substituted by a larger fragmentof the immunoglobulin or the full monoclonal immunoglobulin or by anumber of fragments linked to a carrier protein.
 13. The method of claim1, in which wherein the serum anti-mycolic acid antibodies include thetype that demonstrates cross-reactivity towards sterols.
 14. The methodof claim 9, wherein the scFv has the amino acid sequence of SEQ ID NO:1and/or is encoded by the nucleotide sequence of SEQ ID NO:2 or afragment thereof.
 15. A method for detecting surrogate markers foractive tuberculosis in a serum sample, the surrogate markers beingselected from serum mycolic acid antigen arising from tuberculousmycobacterial infection, serum anti-mycolic acid antibodies arising fromtuberculous mycobacterial infection or both, the method including thestep of exposing a labelled monoclonal antibody having the amino acidsequence of SEQ ID NO:1 and/or which is encoded by the nucleotidesequence of SEQ ID NO:2 or a fragment thereof, to the serum sample. 16.The use of a monoclonal antibody having the amino acid sequence of SEQID NO:1 and/or which is encoded by the nucleotide sequence of SEQ IDNO:2 or a fragment thereof in the manufacture of a device for use in amethod of detecting surrogate markers for active tuberculosis in a serumsample, the surrogate markers being selected from serum mycolic acidantigen arising from tuberculous mycobacterial infection, serum mycolicacid antibodies arising from tuberculous mycobacterial infection orboth.
 17. A monoclonal antibody having the amino acid sequence of SEQ IDNO: 1 and/or which is encoded by the nucleotide sequence of SEQ ID NO:2or a fragment thereof.
 18. A method for detecting surrogate markers foractive tuberculosis in a serum sample, the surrogate markers beingselected from serum mycolic acid antigen arising from tuberculousmycobacterial infection, serum anti-mycolic acid antibodies arising fromtuberculous mycobacterial infection or both, the method including thestep of applying the serum sample and a blank sample to a lateral flowimmunoassay device as claimed in claim 5.